Understanding CKD: Diagnosis,

Stages and Associated

Haemostasis Disorders
Ni Made Hustrini
Division of Nephrology – Department of Internal Medicine
Faculty of Medicine, Universitas Indonesia – Dr. Cipto Mangunkusumo National Hospital
Jakarta – Indonesia
Incidence and
prevalence of
end-stage kidney
disease

Levey AS (2012)
Incidence rate: 200 cases per
million per year
Prevalence rate: 11.5%

Lancet 2012; 379: 165–80

CKD is also a major health issues in Indonesia
Data of CKD epidemiology in Indonesia is scarce
• The Basic Health Research (2018): CKD
prevalence 3.8 permil (‰)
• Prodjosudjadi (2009): CKD prevalence 12.5%

The burden of non-communicable disease (NCD) is high

• Hypertension (34.1%)
• Diabetes (10.9%)
• Stroke (14.7%)

PREVENTION!

Indonesian Renal Registry 2018

Nephrology. 2009;14:669-74
Riset Kesehatan Dasar (Riskesdas) 2018.
Hemodialysis Burden in Indonesia
200000
180000
160000
140000
120000
100000
80000
60000
40000
20000
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
New patients 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446 30831 66433 69124 61786
Active patients 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835 77892 135486 185901 130931

Indonesian Renal Registry 2020

CAPD Rate in Indonesia 2020
3000
2702

2500 2442

2105
2000
1737
1674
1594
1500 1376 1423
1231 1209
1012
1000 840
767 772
639 633
500

0
2011 2012 2013 2014 2015 2014 2015 2016 2017 2018 2019 2020
Jumlah pasien baru Jumlah pasien aktif

Indonesian Renal Registry 2020

The cause of death in HD patients

Unknown
31%
Cardiovascular disease
42%

Others
6%

Sepsis
Gastrointestinal 10% Cerebrovascular
bleeding disease
3% 8%

Indonesian Renal Registry 2020

 DEFINISI PGK

KDIGO 2012
Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

Kidney International Supplements (2013)

KLASIFIKASI PGK
KDIGO 2012
Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

Kidney International Supplements (2013)

KLASIFIKASI PGK (2)

KDIGO 2012
Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

Kidney International Supplements (2013)

Pathogenesis
of CKD
EVALUATION OF CKD - EVALUATION OF GFR

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
EVALUATION OF CKD - EVALUATION OF GFR

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
Sources of error in GFR estimating using creatinine

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
Factors Affecting Serum Creatinine Concentration

Levey AS. Assessing the effectiveness of therapy to prevent the progression of renal disease. Am J Kidney Dis. 1993;22(1):207-214.
The Same Serum Creatinine:
Very Different eGFR
Indications for A Clearance Measurement when
Estimates Based on Serum Creatinine May Be Inaccurate
Is Cystatin C a More Accurate Filtration Marker
than Creatinine?

 Some studies show that serum levels of cystatin C estimate GFR better than
serum creatinine alone.

 Recent studies have clearly demonstrated that cystatin C is a better predictor

of adverse events in the elderly, including mortality, heart failure, bone loss,
peripheral arterial disease, and cognitive impairment, than either serum
creatinine or estimated GFR.

Madero M, Sarnak MJ, Stevens LA. Serum cystatin C as a marker of glomerular ltration rate. Curr Opin Neph Hypertens. 2006;15(6):610-616.
Sarnak MJ, Katz R, Stehman-Breen CO, et al. Cystatin C concentration as a risk factor for heart failure in older adults. Ann Intern Med.
2005;142(7):497-505.
Shlipak MG, Sarnak MJ, Katz R, et al. Cystatin C and the risk of death and cardiovascular events among elderly persons. N Engl J Med.
2005;352(20):2049-2060.
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
How often should GFR be monitored in CKD?

Arici M. Clinical assessment of a patient with chronic kidney disease. In: M. Arici (ed.), Management of Chronic
Kidney Disease, Springer-Verlag Berlin Heidelberg 2014.
Urinalysis And Albuminuria in CKD

 Urinalysis and assessment of albuminuria are very

informative.
 Tests for both screening and diagnosing CKD.

 Role of albuminuria tests:

 defining severity of kidney dysfunction
 estimating prognosis of CKD-related outcomes
 associated cardiovascular risk
 guides treatment

Arici M. Clinical assessment of a patient with chronic kidney disease. In: M. Arici (ed.), Management of Chronic
Kidney Disease, Springer-Verlag Berlin Heidelberg 2014.
Urinalysis

 A complete urinalysis should be carried out in the first examination of

all CKD patients.

 Urinalysis provides important information on clues for underlying

etiologies of chronic kidney disease

 Needs a proper collection of a urine sample.

 First-void (early) morning urine is usually preferred.

Evaluation of Albuminuria

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
Prognosis of CKD by GFR and albuminuria
category

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
Relationship of eGFR and Albuminuria with mortality

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
Clinical Approach to Hematuria
Haemostasis in chronic kidney disease

 Increased risk of bleeding:

 40–50% of patients with chronic renal failure or on haemodialysis (HD).
 The risk of bleeding episodes is increased ∼2-fold in patients with ESKD.

 Increased risk of thrombosis:

 The risk of venous thromboembolism is increased in patients with renal failure.
 Thromboembolism has a 2-fold increased risk in patients with advanced kidney
disease.
 The risk rise when the eGFR falls <75 mL/min/1.73 m2.
Clinical presentation of bleeding and thrombosis in CKD
patients
BLEEDING Gastrointestinal bleeding
Bleeding from cannulation sites
Retinal haemorrhage
Subdural haematoma
Epistaxis
Haematuria
Ecchymosis
Purpura
Bleeding from the gums
Gingival bleeding
Genital bleeding
Haemoptysis
Telangiectasia
Haemarthrosis
Petechiae
THROMBOSIS Deep venous thrombosis
PE
HD vascular access thrombosis
Central venous catheter thrombosis
Central vein thrombosis
Right atrial thrombus
Acute coronary syndrome
Cerebrovascular event
Peripheral artery occlusion
Factors involved in the increased risk of bleeding in
patients with renal failure

Nephrol Dial Transplant (2014) 29: 29–40

Factors involved in the increased risk of thrombosis
in patients with renal failure

Nephrol Dial Transplant (2014) 29: 29–40

Diagnostic Test for Haemostasis Disorders in
CKD

 Skin bleeding time

 Platelet function analyser (in vitro closure time test)
 Platelet aggregation test
 Activating clotting time (ACT)
Conclusion

 CKD is a major health problem in the world with a significant morbidity and
mortality.

 Screening for CKD including the evaluation of eGFR (creatinine or Cys-C) and
urinalysis (albuminuria, hematuria)

 CKD influences haemostasis through different mechanisms which result either

in an anticoagulatory state characterized by recurrent thrombosis or in a
procoagulatory state characterized by episodes of bleeding.
Thank you and stay healthy!